Abstract
This study evaluated a smartphone-based program to promote independent leisure and communication engagement in five participants with visual impairment and mild intellectual disability. A smartphone with Android 5.1 Operating System and S-Voice application, Internet connection, contacts unit, and media player was used. The smartphone was fitted with MP3 files of leisure events and the names and telephone numbers of selected communication partners. The participants were taught to use the smartphone (open the files and reach the partners) through specific verbal utterances. The results showed that all participants learned to use the smartphone. Their independent engagement times (leisure plus communication combined) increased from baseline values of zero to means of between about 75% and 85% of the session lengths. These results indicate that a smartphone-based program may support independent leisure and communication engagement in people with visual impairment and intellectual disability who possess verbal skills.
Introduction
People with visual impairment and intellectual disability may encounter serious problems dealing with leisure and communication activities (Lancioni, Singh, O’Reilly, Sigafoos, Boccasini, et al., 2017; Sutherland et al., 2014; Taylor & Hodapp, 2012). They may fail to independently engage in leisure activities due to the inability to reach and operate computer systems or other leisure devices and/or choose among leisure options (Lancioni et al., 2012; Lancioni, Singh, O’Reilly, Sigafoos, Boccasini, et al., 2017). Similarly, they may require assistance in establishing communication with partners not present in their environment due to the inability to operate telephone devices, which are necessary to activate calls or text messages (Al-Mouth & Al-Khalifa, 2015; Hreha & Snowdon, 2011; Lancioni, Singh, O’Reilly, Sigafoos, Boccasini, et al., 2017).
To address the aforementioned problems and their negative social implications, calls for technology-aided solutions have been made (Hatakeyama, Watanabe, Takahashi, Doi, & Fukuda, 2015; Meder & Wegner, 2015; Sahasrabudhe, Singh, & Heath, 2016). Assessments of such solutions have also been reported. For example, Lancioni, Singh, O’Reilly, Sigafoos, Boccasini, et al. (2017) assessed a program to enable eight participants with visual, intellectual, and motor disabilities to choose among different leisure activity options (e.g., listening to songs or watching videos) and access phone calls or text messages. The program, which was based on an experimental computer-aided system adapted to the participants’ characteristics, presented the options available visually and verbally. The participants were provided with a microswitch for accessing (and choosing within) those options.
Lancioni, Singh, O’Reilly, Sigafoos, Campodonico, et al. (2017) assessed a specially arranged smartphone (i.e., a technology solution cheaper/simpler than the aforementioned computer-aided system) with three participants with blindness and motor disabilities who possessed clearly understandable speech. The smartphone was fitted with leisure activity files and with lists of communication partners and related telephone numbers, and the participants were taught to operate the smartphone (open the files and reach the partners) through specific verbal utterances.
While the results of both studies were largely positive, the number of participants involved was fairly small. In light of this limitation, new studies with additional participants seem warranted to determine the strength and generality of the evidence available (Kazdin, 2011; Makel & Plucker, 2014). This study was designed to extend the assessment of the smartphone-based program with five new participants who presented with total blindness or minimal residual vision and mild intellectual disability (Kazdin, 2011).
Method
Participants
The participants (with the assigned pseudonyms of Andrew, Jane, Thomas, John, and Dave) were between 40 and 49 years of age and attended rehabilitation and activity centers for people with multiple disabilities. Four of them were diagnosed with total blindness while one had minimal residual vision that simply allowed him to perceive objects in his proximity. Psychological records described their functioning as compatible with a level of mild intellectual disability and reported Vineland age equivalences (Sparrow, Cicchetti, & Balla, 2005) ranging from 7 years and 9 months to 9 years and 3 months for communication (with all participants producing clear verbal utterances). They were interested in a variety of leisure activities (e.g., listening to music and comedy sketches and playing guessing games) and also enjoyed phone calls with family members and friends, but depended on external assistance for both types of engagement. In an attempt to reduce this dependence, Andrew and John had previously been exposed to the computer-aided program described above (Lancioni, Singh, O’Reilly, Sigafoos, Boccasini, et al., 2017). The use of a smartphone (a commercially available, typical/normalizing piece of technology) was seen as a practically relevant, advanced solution for all participants including Andrew and John. All participants had expressed their interest in being involved in the study and had asked their legal representatives to sign a formal consent. The study complied with the 1964 Helsinki declaration and its later amendments and was approved by a relevant Ethics Committee.
Setting, sessions, and data recording
Quiet areas of the centers that the participants attended served as the setting for the study. All sessions were conducted on an individual basis and lasted 15 min or until any event selected before the 15-min limit reached its conclusion (e.g., a song or a telephone call ended). Participants had two to four sessions per day. Data recording concerned: (a) the leisure and communication events (e.g., songs and telephone calls) that the participant activated within the sessions and (b) the length of any event-related engagement (i.e., the time period spreading from the activation process to the end of the event). Interrater agreement was assessed in 20% of the participants’ sessions with two research assistants collecting data during those sessions. Agreement, which consisted of the two research assistants reporting the activation of the same events with engagement times differing less than 30 s, occurred in more than 90% of those sessions.
Technology and responses
The technology involved a Samsung Galaxy A3 smartphone with Android 5.1 Operating System and standard functions including S-Voice application, Internet connection, contacts unit, and media player. No specific software was introduced, but the contacts unit and the media player were organized to support the participants’ communication and leisure engagement (see below). In practice, the contacts unit was provided with the names and telephone numbers of 10–12 people (i.e., family members and friends/staff) the participants had indicated as communication partners, that is, partners for telephone calls or text messages. Correspondingly, the media player was provided with a variety of MP3 files dealing with leisure options. The leisure options, which included singers (songs), comedy sketches, games, sport, food recipes, general knowledge (e.g., history and geography) pieces, local chronicles, and weather news, were decided in agreement with the participants and were individualized based on the participants’ personal interests.
At the start of the study, the participants were guided through a voice recognition procedure so that the smartphone would subsequently respond to their verbal utterances. During the sessions, the participants were to initiate any interaction with the smartphone by uttering one of two possible key words, that is, “microphone” or “telephone.” As soon as the smartphone provided a ready signal (i.e., a beep sound), the participant could utter the first request for a communication or leisure option. Requests for a leisure option, such as listening to a comedy sketch, could follow two different patterns. One pattern involved: (a) the participant requesting for a specific comedian, (b) the smartphone asking which of the five sketches available should be played, and (c) the participant indicating the sketch’s number (i.e., one to five). The other pattern involved the participant asking for the comedian and the sketch title and the smartphone playing that sketch. The sketch was played for about 2 min. A sequence comparable to that used for the comedy sketch was available for the various leisure options (e.g., singers/songs, games, general knowledge pieces, and food recipes). All those options could be updated during the study. The participant could (a) interrupt any selected event by uttering the words “microphone” or “telephone” and “stop” and then (b) start a new request sequence following the steps described above.
If the participant asked to call a specific partner (i.e., by uttering the word “call” followed by the name of that partner), the smartphone placed a call to that partner. If the participant asked to send a message to a specific partner, the smartphone waited for a message from the participant and eventually sent it out to the selected partner. The smartphone would read out any incoming message in response to a specific request (i.e., “read messages”) by the participant.
Experimental conditions
The study was carried out according to a non-concurrent multiple baseline design across participants (Barlow, Nock, & Hersen, 2009). That is, the participants received two to six baseline sessions before being exposed to the intervention and the post-intervention phase. Four research assistants, experienced in the use of technology-aided programs with persons with multiple disabilities (and coordinating with one another during the study), were in charge of the sessions and of data recording.
Baseline
At each baseline session, the research assistant (a) invited the participant to use the smartphone through verbal utterances or conventional touch inputs and (b) listed the options available (e.g., making phone calls and listening to songs). If the participant failed to use the smartphone after about 4 min (as expected given his or her unfamiliarity with such device and the responses it required), the research assistant activated a song, a game, or a telephone call, thus reducing possible frustration.
Intervention
In all, 8–11 intervention sessions were available for each participant. During those sessions, the research assistant was to ensure that the participant successfully practiced verbal requests for leisure and communication options. Initially, the research assistant modeled the response sequences needed to make such requests and access the related options. Then, the research assistant’s modeling was delayed and reduced to the parts of the response sequences that the participant was unable to manage. Eventually, modeling was eliminated and the participant was to manage the response sequences needed for the various options independently.
Post-intervention
During the 97–124 post-intervention sessions, the participants did not receive any specific help from the research assistant except for possible reminders about the leisure and communication options available to them.
Results
Table 1 summarizes the participants’ data for the baseline (i.e., pre-intervention) and post-intervention phases. For each phase, the table reports the participants’ number of sessions and the mean percentages of session time spent with smartphone-mediated leisure and communication events. The table does not include the data of the 8–11 intervention sessions, which were set up to enable the participants to independently use the smartphone (see above).
Numbers of baseline and post-intervention sessions and mean percentages of session time spent with leisure and communication events during those phases.
During the baseline sessions, the participants did not manage to activate leisure or communication events via the smartphone, thus the mean percentages of session time spent with independently activated leisure and communication events were zero. During the post-intervention phase (i.e., after the 8 to 11 intervention sessions), the participants were able to use the smartphone independently and engaged in leisure and communication events extensively. Their mean percentages of session time spent engaging in leisure events ranged from 51 to 73; their mean percentages of session time spent engaging in communication events ranged from 3 to 29. Their total engagement times (leisure plus communication times combined) reached means of between about 75% and 85% of the session lengths.
Discussion
The results underline the applicability and effectiveness of a smartphone-based program to support leisure and communication in people with blindness or minimal residual vision and mild intellectual disability, thus extending the data recently reported by Lancioni, Singh, O’Reilly, Sigafoos, Campodonico, et al. (2017). In practice, the participants learned to use the voice recognition function of the smartphone and benefited from the specific arrangements made in the contacts unit and the media player of the device (i.e., storing names with related numbers and leisure material files). Obviously, the application of the smartphone-based program presupposes that the participants are verbally skilled. For participants without such skill, the computer-aided program mentioned in the introduction would appear the only realistic alternative (Lancioni, Singh, O’Reilly, Sigafoos, Boccasini, et al., 2017).
The participants’ high and consistent levels of engagement time during the post-intervention sessions may be taken to indicate that (a) the smartphone-based program was largely suitable to the participants’ characteristics and (b) the participants were motivated to be active. With regard to the motivation aspect, one can argue that both the leisure and the communication opportunities available to the participants had a positive connotation and thus could be seen as motivating per se (Catania, 2012; Pierce & Cheney, 2008). Unfortunately, no data were collected as to the participants’ perception of the program sessions. That is, no checks were conducted to verify whether the participants favored those sessions over other forms of engagement available within their daily context.
Besides addressing the aforementioned question, future research should also concentrate on replication, generalization, and social validation issues. Direct and systematic replication trials would help determine the strength of the present program and the feasibility of adaptations thereof to accommodate the needs of different participants (Kazdin, 2011; O’Rourke et al., 2014). Assessing the participants’ ability to use the program in settings other than their rehabilitation and activity centers (i.e., checking for generalization effects) would help clarify the overall suitability and potential implications of the program (Pierce & Cheney, 2008). Social validation assessments of the program would provide a picture of staff and caregivers’ views about the benefits and applicability of the program (Luiselli, Bass, & Whitcomb, 2010). Positive social validation data could be a favorable omen for the adoption and regular use of the program within daily contexts.
An additional point for new studies to address is the research assistants’ procedural reliability. In this study, such reliability was presumed based on the fact that research assistants (a) were experienced in the use of technology-aided programs and knowledgeable about previous work in this area (Lancioni, Singh, O’Reilly, Sigafoos, Campodonico, et al., 2017) and (b) coordinated with one another during the study. Even in the presence of these favorable conditions, reliability checks would remain an important requirement to ascertain procedural dependability.
In conclusion, preliminary data seem to indicate that a smartphone-based program may support independent leisure and communication of people with visual impairment and intellectual disability who possess verbal skills. New research will need to address the issues mentioned above and possibly strengthen the applicability of the program in daily contexts.
Footnotes
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.